Cooking Up an Anesthetic

I have been on-call quite a bit this month. Today I am post-call and off for the weekend, ah...


For lunch I wanted Linguini Aglio Olio. Unfortunately this is not so straight-forward without the olio. How can there be no olive oil in my kitchen? After scrambling around for a bit I ended up using some olive oil spray, a teaspoon of butter, and a couple of drops of canola oil and to my great surprise, the dish came out edible and pretty tasty. But I guess it's not that easily messed-up as dishes go!


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When I was a medical student I watched a senior anesthesia resident during a case, tweaking the rate of IV fluid administration here, adjusting the dial on the vaporizer there. It all seemed so mysterious - why did he pick that particular moment to turn the gas flow up a notch or down a notch? The patient looked just the same. I asked him, "How do you know when to do that?" He answered laconically, "Practice."

As I learned to do the job, and found myself making the very same moves, I asked myself the same question, and my answer was, "Cooking." How many times have I turned the heat up or down on garlic being sautéed in the pan, or added an ingredient to a simmering sauce, or taken a spoon to toss a vegetable around, simply because my instincts told me it was the right move for that moment? And how did these instincts arise? From making the dish a number of different ways about a hundred times.




I find there's a lot in common between delivering anesthesia and cooking without a recipe (though when I mentioned this comparison during residency once, my attending shot it down instantly with a, "No there isn't." Different strokes...). I emphasize without a recipe, because with the exception of resuscitation algorithms, recipes can make for faulty medical practice. It's true that there are drugs and techniques I can say I usually use for any given case, but I try to practice flexibly. The minute we start handing out drugs according to some preconceived "cookbook" - remifentanil and propofol for this, midazolam and fentanyl for that, every time, all day, every day - we've stopped using judgment, creativity, knowledge, and adaptability. We've stopped being physicians, designing anesthetics in an actively engaged way, taking into account the needs of each particular patient or case.

Moreover, very often plan A just doesn't work out. No one starts the day wanting to perform an awake fiberoptic intubation on someone, but if safety concerns arise, and it's the right decision, then plan B it is. It's not what the patient wants, and it's not what I want in terms of comfort for my patient - but it's the right thing to do, and it's not a judgment I would make lightly. Cases like that highlight the folly of a consumer model of health care delivery. "Customer satisfaction" - or its equivalent, patient satisfaction, because patients are not customers - comes second; patient safety comes first. Always.

That said, I try my best every day to be open with my patients, hear their concerns, and carry out a plan that results in maximal safety and comfort for everyone. This is why when a patient once adamantly said she did not want a particular drug, and I was trying to ask questions to clarify my understanding of her experience and her position (i.e. doing my job), so that I could come up with a safe and viable alternative, I was offended and irritated when her husband yelled at me, "Why do you people always start asking all these questions the minute she says that? She doesn't want it, period! We don't need all these questions!" Well, sir, you're wrong, we do need these questions if we're going to be prepared and provide the best care we can for your wife. It's a shame you're too short-sighted and hot-tempered to appreciate that, but that's the truth of it. I didn't reply in those words, of course, but I said to his wife something like, "Your experience with this drug is important for me to know about, because I care about making your comfortable and keeping you safe. Could you tell me a little more about the reaction you had...?"

Speaking of communication, a couple of things keep coming up (most recently, just last night) that I want to highlight because they really help us anesthesia folks provide the safest anesthetic we can (the following is just a sample; I'm sure I could think up more):

-Please follow any instructions you receive about eating and drinking prior to surgery, to the letter (usually some variation of DON'T eat or drink for 8 hours prior). And if you have consumed anything, please say so - this is a SAFETY issue.

-Please remove all contact lenses and piercings. Yes, even those piercings. :)

-If you drink 12 beers a day, please don't say you only drink on holidays. First of all, it's not safe to understimate the amount, because then we might incorrectly estimate the anesthetic dose for you. Secondly, once you are under, we can tell. Trust me. Your body will reveal to us that you in fact drink ten times more than you say you do.

-If you just had cocaine yesterday, or today, please don't tell us you've been off it for months. Again, it's NOT SAFE. And again, once you're unconscious, we'll be able to tell that your body is in fact totally revved on crack. But more importantly, something really BAD could happen to you on the table that we can do something to prevent if we know ahead of time, and we'll be able to choose the RIGHT drugs to help you, as opposed to the drugs that might indirectly contribute to your having a brain hemorrhage.

-Last but not least, please, please, please tell us what you're most concerned about. Your anesthesiologist should WANT to listen and do everything in his or her power to care for you attentively and safely. Please also hear us out if there's something we're concerned about explaining, from our end of things. We are NOT trying to be pains in the neck, but rather to provide thorough and good care. Our job is to protect and watch over you, and most of us do take that very seriously and wish to do our best.

Have You Hugged Your Anesthesiologist Today?

That’s it. I’ve had it. I’ve read yet another piece of writing that demonstrates a complete lack of understanding of what anesthesiology is and entails, and I need to vent.

So allow me to lower the mysterious drapes for a moment and let you into my world.

No one gets up one day and says, “I want to be an anesthesiologist when I grow up.” I wanted to be a ballerina, or a bookstore-café owner, or an artist of some kind – someone who was required to pay close attention to the world, take real notice of it, and take creative and compassionate action. But I am neither a ballerina nor a bookseller. I am an anesthesiologist.

Frequently people ask me a version of “What on earth made you choose that?” I try to explain that I love the way anatomy and physiology come alive moment-to-moment in daily practice. Or I try the concrete approach and admit that I actually enjoy placing intravenous lines and breathing tubes. The response I get is usually a glassy-eyed “Uh-huh” or, occasionally, a nose-wrinkling “Eew.” If the conversation progresses beyond “eew,” the more people talk to me about what they think I do – that is, if they think I actually do anything in the first place – the more bewildered I get over how difficult it is to convey to others an understanding of my work.

One time I visited a patient the day before her planned surgery. After I explained what she could expect, she exchanged a few words with her family in her native language. They clearly assumed I couldn’t understand them. An older woman instructed my patient not to bother asking me too many questions, saying, “She’s just an anesthesiologist; what do they know?”

After years of annoyance at many people’s assumptions that I was not a physician because of my gender or my young appearance, this remark – not the first I’d heard along those lines – made me take stock. I realized that not even other physicians understand what we anesthesiologists do, sitting back there in our little cockpits behind some blue drapes (“the blood/brain barrier”), periodically looking up at large machines but appearing otherwise idle. One doctor asked me once, “You have to take an oral exam? For anesthesia? Is there enough material in anesthesiology for an oral exam?” Considering the profound suffering the ordeal of the orals caused me, and causes many anesthesiologists, I felt like shaking the guy by the hair – except he didn’t have any. If other doctors don’t get it, how could I hope to find anything but murkiness and misunderstanding in the perceptions of non-doctors?

I did a little experiment. I constructed a detailed questionnaire about what kind of physician people would want to come to their rescue if they collapsed in a public place. No one wrote down that they would be glad if an anesthesiologist were around.

I figured out about four broad, wide-spread misconceptions about anesthesiologists:
-we are not doctors
-what we do is easy
-we don’t establish rapport with our patients
-if anything goes wrong, “it’s Anesthesia’s fault.”

Then I realized something else: because people have absolutely no idea what to imagine about our work, they decide to make stuff up. It’s amazing.

People react to the mysterious in one of three ways: with fear, with fabrication, or with efforts to deepen their understanding. The fear I see daily. The fabrication – well, let’s just say if I hear one more person declare that all I do is put people to sleep, then sit next to my anesthesia machine and—what? Daydream? Wait for the patient to wake up? Twiddle my thumbs?—that will be one person too many. But that is what people say.

I have heard more times than I can count, “Well, all you do is knock people out. How hard can that be?” My hairdresser asked me when we first met, “So, once you put the patient to sleep, do you leave the room since your job is done?” Excuse me? My job is done? Then who did he think was keeping the patient alive while the surgeon was mucking around with his vital organs and causing all sorts of dangerous disturbances to his vital signs? Who was going to make judgments about what was specifically appropriate for that patient’s particular brand of heart defect, or lung disease, or neurologic abnormality? And then there’s my personal favorite: “You mean, anesthesia for appendicitis is different from anesthesia for heart surgery?” Hmm. 1-inch abdominal incision versus sawing through a person's chest. Yes, it's different.

My husband once tried to mollify my irritation by pointing out that people just couldn’t be expected to know about anesthesia. “Do you know what a machinist does? Or a gaffer?” To which I replied, “Of course not. I have no idea. But I don’t assume that their jobs are easy, and I don’t presume that their work can be summed up by one simple task.” Even my lawyer husband had to admit I had a point. “Well,” he said, “what DO you do, and what do you want people to know about it?”

I don’t think of myself as a doctor whose function is to induce sleep. My primary function is to resuscitate those who need resuscitating. Yes, about 1% of what we do does involve calculating the appropriate dose of the appropriate drug, drawing it up into a syringe, and injecting it into the veins of people who would like to avoid feeling pain or hearing unfamiliar noises during surgery. But I spend most of my energy making sure that I can bring them back. Designing an anesthetic is a thoughtful act. My resuscitation of my patients often begins the night before I meet them, when I am going over safety plans in my head.

Most of my training, in fact, was focused on becoming an expert at resuscitation in its various forms – reviving patients who were dead or near death; intubating those who could not breathe; rehydrating the dehydrated; unparalyzing those I had paralyzed chemically for surgical purposes; awakening the unconscious with judicious use of anesthetic drugs and gases; creating pain relief and anti-nausea regimens for the afflicted; and making sure failing heads, hearts, or lungs functioned well enough to ensure survival of a given surgical procedure.

Late in my training, I realized our level of expertise when I asked a resident in a different specialty – one whose members also take pride in their resuscitation skills – how many intubations she had done after two years. I was expecting to hear perhaps half of my quota of about 1200. “I’ve logged about 84,” she replied. And this was the physician-type people wanted nearby if they collapsed in a public place and needed a breathing tube to stay alive.

Anesthesia affects consciousness, blood pressure, heart rate, respiration, and a whole host of other body processes. If I am not there to watch over you, that first injection can harm you. And that’s just the first step. I should be breathing for you if you stop (and you will), administering fluids when your surgeon nicks a “bleeder,” and giving you the medications you need to wake up safely and comfortably. This can mean a lot of scurrying around, checking, and readjusting within the confines of my “cockpit.” Is the IV running too fast? Is the machine blowing in enough air with each breath? How’s the urine output? Oh, they’re closing – should I turn the gas down now, or will he take a while? Is that heart rate a little too high for his aortic or mitral valve problem? Did I give the drug to slow it down? Let me dive down under the drape to make sure his eyes are still protected…This is all behind-the-scenes, largely unacknowledged work, but it makes even the tiniest task a meaningful act, and I love that about my job.

And that’s just in the O.R.

I've written elsewhere about my E.R. and I.C.U. intubations, but I haven’t even addressed the expertise anesthesiologists bring to laboring women, not only in placing and ensuring the safety of epidurals for labor and spinals for C-section at any given moment, day or night, but also in caring for mothers when childbirth becomes dangerous. On occasion help is needed for an alarmingly sluggish newborn, and yes, we are useful for that too. The code that made my heart beat the fastest was when “Anesthesia, Stat” was paged overhead to the labor and delivery suite and I realized the person coding wasn’t one of the moms, but rather a minutes-old newborn. The family practice attending physician handed over the laryngoscope he was holding, and I intubated the baby so we could bring her oxygen saturation back up to liveable.

Many people have assumed that their limited understanding of our profession reflects a limited scope of medical practice on our part. Assumptions can be unfortunate, but I prefer to focus on the things that keep me coming back to the O.R. despite people’s colossal lack of awareness about what I try to do for them. I know what you’re thinking: it’s gotta be the paycheck, right? Never mind that childcare costs and six-digit educational loans eat up half of it. Sure, the pay is good, but it’s good because of what we are capable of doing for people, and the amount of sweat and tears it took to acquire and prove those capabilities. This is not a job you can commit to just for the pay and be truly happy. It’s too hard.

Nor can anesthesiologists be motivated simply by glamour and prestige – there’s too much ignorance about anesthesiology to allow for either. For me, real job satisfaction has to rest on tenacity, self-respect, humility, kindness, and happiness with the work itself. The big pay-off, in my mind, lies in my relationships with my patients, whom I may meet only briefly but during intensely significant moments in their lives, when they may need the most comfort. All the scientific gobbledygook that goes into the practice of anesthesiology has a chance to get sifted and transformed into a true human connection, into resuscitation that goes well beyond the needs of the body.

It’s my hope that someday, when a person collapses in the bookstore-café that I don’t own, or in the opera house in which I’m not dancing (or playing the oboe!), and an anesthesiologist responds, it will be common knowledge that the professional responding to the situation is providing expert care in the truest sense of the phrase.